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Coumadin Management

Wendy Bodwell, MSN, RN, NHA, CNAA

Coumadin deficiencies with high levels of scope and severity are being cited frequently by surveyors.  Common cites include residents who missed doses of Coumadin, residents who recieved too much Coumadin, and residents who did not receive adequate International Normalized Ratio (INR) monitoring.

Administrators, DONs, Medical Directors, and Consultant Pharmacists need to make Coumadin administration and monitoring a priority.  This requires intense follow up in all buildings, but especially in facilities using agency staff.   A comprehensive coumadin monitoring system should be initiated. 

 The monitoring system should address the following issues:     

·        The facility is responsible for providing adequate drug references on each medication cart.   These references should be current, i.e., 2000 Mosby’s Drug Reference, etc.  A current PDR should be readily available as well as a current (within the past 3 years) medical-surgical textbook.  All out-of-date references should be removed from the facility. 

·        Nurses are accountable for understanding the indications, contraindications, and common side effects of the drugs they are administering.  Supply them with the training and resources to support this complex task, but hold them to this accountability.   

·        A common source of error occurs at the month-end comparison of MARs.  The facility is responsible to make sure that the process of comparing the current month’s physician order sheets with the next month’s order sheets is reasonable.  This means that the nurse should do the checking in a place where there are minimal interruptions.  The nurse should not be checking the medication sheets while she is also required to be doing procedures or monitoring the floor.  If this is the case, someone else should be scheduled to work the floor while the nurse is checking the order sheets.  

·        The month-end comparison should not be the sole responsibility of the nurse.  A double check system can help ensure that no errors occur as a result of the comparison process.  For example, the nurse checking the month-end order sheets can place a check mark next to each medication that she has verified.  The completed sheets can then be reviewed by the DON to ensure that there are check marks by every medication.  The DON can sign off that all medications were checked if there are check marks placed by every entry.   This is an easy way to support the process, and is not too time-consuming for the DON.

·        To prevent missed doses of coumadin, institute a system to prevent  “med holes.”  Having the nurse from the outgoing shift review the MARs with the nurse from the oncoming shift (as they do for the narcotic count) is a way to quickly spot areas on the MAR which have not been signed off. 

 ·        Nurses should not have to look at the bottom of the MAR to find residents’ diagnoses.   Make sure that all medications listed on the MAR have a diagnosis written in right next to the dose.  The coumadin order should specify whether it is being given for venous thromboembolism, stroke prophylaxis in atrial fibrillation, or stroke prophylaxis in mechanical heart valves.    

·        INRs are the most reliable measurement of how anticoagulated the resident is.  At a minimum, INRs should be done every 30 days.  Every week or two may also be appropriate.  The facility needs to communicate the 30-day minimum policy to all physicians.  When the facility receives the INR result from the lab, the physician should immediately be notified.  If the resident is within the desired INR range, the nurse should go ahead and give the dose as previously ordered by the physician.  If the resident is not within the desired INR range, the nurse should hold the next dose of coumadin until the physician calls back with a new order.

 ·        Antibiotics increase the INR.  Before writing an antibiotic order, nurses should notify the physician that the resident is on coumadin.   An order for more frequent INRs should be obtained.  This communication should be docu’mented in the chart.  

·        Various medications can decrease the INR, such as haldol, dilantin, hydochlorothiazide.  Have an easily accessible "“cheat sheet” of drugs that affect INRs on every medication cart.

 ·        Although all drugs may be given with coumadin, some drugs and conditions warrant special attention.  Examples include (but are not limited to) residents with hypertension, who should be watched for changes in mental status related to cerebral bleeding, and residents with frequent falls, who should be monitored for signs of bruising or bleeding.  Communication with the physician is imperative in these cases.

 ·        Nurses should not have to look in multiple places for information regarding coumadin.  In addition to the diagnosis for the coumadin, what nurses need to know prior to administering coumadin is the date of the most recent INR, the most recent INR value, what the coumadin dose was changed to, (or if there was no change) and when the next INR is ordered.  All of this information should be kept in a flow sheet for each resident on coumadin.  This should be kept in the MAR, so the nurse checks the information before administering the drug.    

 ·        The DON should know which residents in the facility are on coumadin.  She must follow up on these residents to ensure that INRs are indeed being done every 30 days.  She can easily do this by checking the flowsheets.  The DON needs to follow up with individual nurses to make sure the flowsheets are being updated.   This follow up by the DON should be done weekly in buildings with complex residents or in facilities that use agency staff.

 ·        The Consultant Pharmacist provides a check and balance to the coumadin monitoring system.   The pharmacist should specifically monitor the residents on coumadin, and whether they are receiving the appropriate INRs, and if the flow sheets are being kept up.

 ·        The DON and the Consultant Pharmacist should report monthly on the results of the coumadin monitoring system to the facility QA Committee. Action plans should be developed to correct any trends that show up. 

 ·        The Administrator is responsible to support the coumadin administration and monitoring process in any way possible - it is not just the responsibility of the DON.

 ·        All nurses should be trained on coumadin as well as the coumadin monitoring system in the facility.  The training should include the indications for coumadin, side effects, what to watch for, drug interactions, the policy for how often INRs must be done, and use of the flowsheet.  This training should be done for all nurses upon hire, and should be reviewed annually. 

For any questions regarding coumadin monitoring, contact Wendy Bodwell, Administrator, Centura Geriatric Center, 303.899.5411, or wendybodwell@centura.org.

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